EP4164641A1 - Alk2 inhibitors for the treatment of anemia - Google Patents

Alk2 inhibitors for the treatment of anemia

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Publication number
EP4164641A1
EP4164641A1 EP21739843.7A EP21739843A EP4164641A1 EP 4164641 A1 EP4164641 A1 EP 4164641A1 EP 21739843 A EP21739843 A EP 21739843A EP 4164641 A1 EP4164641 A1 EP 4164641A1
Authority
EP
European Patent Office
Prior art keywords
compound
formula
mds
administered
anemia
Prior art date
Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
Pending
Application number
EP21739843.7A
Other languages
German (de)
English (en)
French (fr)
Inventor
Francis SÉGUY
Ekaterine ASATIANI
Yaoyu CHEN
Current Assignee (The listed assignees may be inaccurate. Google has not performed a legal analysis and makes no representation or warranty as to the accuracy of the list.)
Incyte Corp
Original Assignee
Incyte Corp
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Incyte Corp filed Critical Incyte Corp
Publication of EP4164641A1 publication Critical patent/EP4164641A1/en
Pending legal-status Critical Current

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Classifications

    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
    • A61K31/4427—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems
    • A61K31/4439—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems containing a five-membered ring with nitrogen as a ring hetero atom, e.g. omeprazole
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
    • A61K31/455—Nicotinic acids, e.g. niacin; Derivatives thereof, e.g. esters, amides
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K9/00—Medicinal preparations characterised by special physical form
    • A61K9/0012—Galenical forms characterised by the site of application
    • A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P7/00—Drugs for disorders of the blood or the extracellular fluid
    • A61P7/06—Antianaemics

Definitions

  • cytokines e.g., in IL-6
  • the standard of care primarily comprises supportive care for their symptoms: RBC transfusions and ESAs for anemic patients and management of risk of bleeding and infections.
  • Chronic anemia and RBC transfusions are independent risk factors affecting survival and are associated with iron overload, fatigue, impaired quality of life, and increased cardiovascular risks.
  • ESAs can provide clinical benefit to some patients with MDS. However, only approximately 30% of patients treated with ESAs achieve improvement. The benefit is usually limited to a minority of patients that have low erythropoietin level at baseline.
  • Anemia also impacts those suffering from multiple myeloma (MM): nearly all patients with MM will be affected by anemia during the course of their disease.
  • Multiple myeloma is a malignant plasma cell dyscrasia characterized by a clonal proliferation of plasmatic cells in bone marrow, and monoclonal gammopathy.
  • Symptomatic patients and their need for therapy are defined by the presence of hypercalcemia (C), renal insufficiency (R), anemia (A), and/or bone lesions (B) according to the CRAB criteria (Kyle, R.A.; Rajkumar, S.V. Leukemia 2009; 23:3-9).
  • C hypercalcemia
  • R renal insufficiency
  • A anemia
  • B bone lesions
  • Ri of the compound of Formula I can be bridged Cs- cycloalkyl substituted with hydroxy.
  • F3 ⁇ 4 of the compound of Formula I can be tetrahydropyran.
  • the compound of Formula I can be the compound 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-(3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan- 1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I can also be 2-amino-N-(4-hydroxybicyclo-[2.2.2]octan-1- yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan-1- yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I can also be 2-amino-N-(4-hydroxybicyclo[2.2.2]octan-1- yl)-5-(4-((1S,5R)-3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan-1- yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I can also be 2-amino-N-(4-hydroxybicyclo[2.2.2]octan-1- yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan-1- yl)phenyl)nicotinamide fumarate dihydrate.
  • the subject can suffer from a myelodysplastic syndrome (MDS).
  • MDS myelodysplastic syndrome
  • MDS-MLD multilineage dysplasia
  • MDS-SLD MDS with single lineage dysplasia
  • MDS-EB MDS with excess blasts
  • MDS-U MDS with isolated del(5q)
  • MDS-U MDS unclassifiable
  • the subject in the method of treating anemia can also suffer from myelodysplastic syndrome and myeloproliferative neoplasms (MDS/MPN) overlap syndromes such as chronic myelomonocytic leukemia (CMML) and unclassifiable MDS/MPN overlap syndromes.
  • MDS/MPN myelodysplastic syndrome and myeloproliferative neoplasms
  • CMML chronic myelomonocytic leukemia
  • unclassifiable MDS/MPN overlap syndromes unclassifiable MDS/MPN overlap syndromes.
  • the anemia of the method provided herein can be iron-refractory iron deficiency anemia (IRIDA).
  • IRIDA iron-refractory iron deficiency anemia
  • the subject can suffer from myelofibrosis (MF).
  • MF myelofibrosis
  • the subject suffering from MF can be transfusion-dependent or not transfusion-dependent.
  • the compound of Formula I can be administered orally.
  • the compound of Formula I can also be administered as a monotherapy for the treatment of anemia. This compound can be administered at a dose of about 5 mg to about 500 mg once daily (QD), or more particularly at a dose of about 50 mg once daily (QD).
  • QD dose of about 5 mg to about 500 mg once daily
  • QD dose of about 50 mg once daily
  • the compound of Formula I can be administered as a 5 mg, 25 mg, or 50 mg tablet, or a combination thereof.
  • Also provided herein is a method of reducing hepcidin levels in a subject in need thereof, comprising administering to the subject a compound of Formula I, or a pharmaceutically acceptable salt thereof.
  • the subject of the method of reducing hepcidin levels can suffer from anemia.
  • the anemia can be iron-refractory iron deficiency anemia (IRIDA).
  • IRIDA iron-refractory iron deficiency anemia
  • the subject can be either transfusion-dependent or not transfusion-dependent.
  • MDS myelodysplastic syndrome
  • MDS-MLD multilineage dysplasia
  • MDS-SLD MDS with single lineage dysplasia
  • MDS-EB MDS with excess blasts
  • MDS-U MDS unclassifiable
  • the subject of the method of reducing hepcidin levels can suffer from multiple myeloma (MM).
  • the subject of the method of reducing hepcidin levels can suffer from myelofibrosis (MF).
  • the subject of the method of reducing hepcidin levels can suffer from myeloproliferative neoplasms (MPN).
  • MPN myeloproliferative neoplasms
  • the subject of the method of reducing hepcidin levels can suffer from chronic kidney disease (CKD).
  • the compound of Formula I can be administered orally.
  • the compound of Formula I can also be administered as a monotherapy for the treatment of anemia. This compound can be administered at a dose of about 5 mg to about 500 mg once daily (QD), or more particularly at a dose of about 50 mg once daily (QD).
  • QD dose of about 5 mg to about 500 mg once daily
  • QD dose of about 50 mg once daily
  • the compound of Formula I can be administered as a 5 mg, 25 mg, or 50 mg tablet, or any combination thereof.
  • Figure 2 shows the results of prophylactic dosing in the left panel and concomitant dosing in the right panel of the kidney disease-anemia model where ** p ⁇ 0.01 ; *** p ⁇
  • Hepcidin is a small peptide hormone primarily synthesized in hepatocytes that reduces both duodenal iron absorption and iron export from monocytes and macrophages by binding to and inducing the internalization and degradation of the iron exporter ferroportin (Nemeth E, et al. Science. 2004;306:2090-2093; Theurl I, et al. Haematologica. 2011; 96:1761-1769, Zhao N, Zhang AS, et al. J Clin Invest. 2013;123(6):2337-2343).
  • the elevated serum hepcidin levels enhance storage of iron within the reticuloendothelial system and result in reduced iron availability and iron restricted erythropoiesis. Inappropriately increased hepcidin expression causes severe functional iron deficiency anemia in humans and is central to the pathophysiology of anemia of chronic disease (Weiss G, Goodnough LT. N Engl J Med 2005;352:1011-1023).
  • ALK2 activin receptor-like kinase-2
  • BMP bone morphogenetic protein
  • CMML chronic myelomonocytic leukemia
  • Serum hepcidin has been shown to be significantly higher in MM patients compared to healthy individuals and age-matched controls (Ibricevic-Balic et al, Med Arch. 2016 Dec;70: 429-432; Victor et al, Clin Lab. 2017;63:1273-1277; and Maes et al, Blood. 2010; 776:3635-3644).
  • Patients with stage III MM at diagnosis had higher urinary hepcidin levels than normal controls.
  • Hepcidin serum levels are inversely correlated with hemoglobin concentrations in MM patients (Katodritou et al, Am J Hematol.
  • Iron deficiency anemia occurs when red blood cell counts are low due to a lack of iron. While iron deficiency anemia is generally an acquired disease due to insufficient iron in the person's diet or chronic blood loss, IRIDA is an autosomal recessive condition that results from mutations in TMPRSS6 gene, which causes iron deficiency (Bhatia, P, et al. Pediatr. Hematol. Oncol. J. 2017; 2; 48-53). Common forms of acquired iron deficiency anemia are commonly treated by oral iron supplements or intravenous (IV) iron infusions, but patients with IRIDA will not respond fully to those treatments.
  • IV intravenous
  • Intractable anemia depresses quality of life, portends poor outcomes, and can act to restrict access to palliative JAK inhibition in some patients. While therapies for MF-related anemia do exist, they are limited in their efficacy, durability, and tolerability.
  • the articles “a” and “an” refer to one or to more than one (i.e., to at least one) of the grammatical object of the article.
  • an element means one element or more than one element.
  • use of the term “including” as well as other forms, such as “include,” “includes,” and “included,” is not limiting.
  • treating refers to inhibiting a disease; for example, inhibiting a disease, condition, or disorder in an individual who is experiencing or displaying the pathology or symptomology of the disease, condition, or disorder (i.e., arresting further development of the pathology and/or symptomology) or ameliorating the disease; for example, ameliorating a disease, condition, or disorder in an individual who is experiencing or displaying the pathology or symptomology of the disease, condition, or disorder (i.e., reversing the pathology and/or symptomology) such as decreasing the severity of the disease.
  • prevent comprises the prevention of at least one symptom associated with or caused by the state, disease or disorder being prevented.
  • the term “patient,” “individual,” or “subject” refers to a human or a non-human mammal.
  • Non-human mammals include, for example, livestock and pets, such as ovine, bovine, porcine, canine, feline and marine mammals.
  • the patient, subject, or individual is human.
  • transfusion dependent means that a subject receives regular platelet and/or red blood cell (RBC) transfusions more frequently than every 8 weeks due to persistently low platelet and/or RBC counts.
  • the term “monotherapy” means that the treatment uses a single active pharmaceutical ingredient to treat a disease or condition.
  • a monotherapy can still include treatment with a pharmaceutically acceptable carrier or excipient.
  • the single active pharmaceutical ingredient is a compound of Formula I.
  • a compound of Formula I is administered as a monotherapy not in conjunction with a Janus kinase inhibitor.
  • the term “pharmaceutically acceptable” refers to a material, such as a carrier or diluent, which does not abrogate the biological activity or properties of the compound, and is relatively non-toxic, i.e., the material may be administered to an individual without causing undesirable biological effects or interacting in a deleterious manner with any of the components of the composition in which it is contained.
  • the term “pharmaceutically acceptable salt” refers to derivatives of the disclosed compounds wherein a parent compound is modified by converting an existing acid or base moiety to its salt form.
  • pharmaceutically acceptable salts include, but are not limited to, mineral or organic acid salts of basic residues such as amines; alkali or organic salts of acidic residues such as carboxylic acids; and the like.
  • the pharmaceutically acceptable salts described herein include the conventional non-toxic salts of the parent compound formed, for example, from non-toxic inorganic or organic acids.
  • the pharmaceutically acceptable salts discussed herein can be synthesized from the parent compound which contains a basic or acidic moiety by conventional chemical methods.
  • such salts can be prepared by reacting the free acid or base forms of these compounds with a stoichiometric amount of the appropriate base or acid in water or in an organic solvent, or in a mixture of the two; generally, nonaqueous media like ether, ethyl acetate, ethanol, isopropanol, or acetonitrile are used.
  • pharmaceutically acceptable salt is not limited to a mono, or 1 :1, salt.
  • “pharmaceutically acceptable salt” also includes bis-salts, such as a bis-hydrochloride salt. Lists of suitable salts are found in Remington's Pharmaceutical Sciences, 17th ed., Mack Publishing Company, Easton, Pa., 1985, p. 1418 and Journal of Pharmaceutical Science, 66, 2 (1977), each of which is incorporated herein by reference in its entirety.
  • composition refers to a mixture of at least one compound with a pharmaceutically acceptable carrier.
  • the pharmaceutical composition facilitates administration of the composition to a patient or subject. Multiple techniques of administering a compound exist in the art including, but not limited to, intravenous, oral, aerosol, parenteral, ophthalmic, pulmonary, and topical administration.
  • the term “pharmaceutically acceptable carrier” means a pharmaceutically acceptable material, composition or carrier, such as a liquid or solid filler, stabilizer, dispersing agent, suspending agent, diluent, excipient, thickening agent, solvent or encapsulating material, involved in carrying or transporting a compound useful to the patient such that it may perform its intended function.
  • a pharmaceutically acceptable material, composition or carrier such as a liquid or solid filler, stabilizer, dispersing agent, suspending agent, diluent, excipient, thickening agent, solvent or encapsulating material, involved in carrying or transporting a compound useful to the patient such that it may perform its intended function.
  • Such constructs are carried or transported from one organ, or portion of the body, to another organ, or portion of the body.
  • Each carrier must be “acceptable” in the sense of being compatible with the other ingredients of the formulation, including the compound disclosed herein, and not injurious to the patient.
  • materials that may serve as pharmaceutically acceptable carriers include: sugars, such as lactose, glucose and sucrose; starches, such as corn starch and potato starch; cellulose, and its derivatives, such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; powdered tragacanth; malt; gelatin; talc; excipients, such as cocoa butter and suppository waxes; oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil and soybean oil; glycols, such as propylene glycol; polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol; esters, such as ethyl oleate and ethyl laurate; agar; buffering agents, such as magnesium hydroxide and aluminum hydroxide; surface active agents; alginic acid; pyrogen-free water; isotonic saline
  • “pharmaceutically acceptable carrier” also includes any and all coatings, antibacterial and antifungal agents, and absorption delaying agents, and the like that are compatible with the activity of a compound disclosed herein, and are physiologically acceptable to the patient. Supplementary active compounds may also be incorporated into the compositions.
  • the “pharmaceutically acceptable carrier” may further include a pharmaceutically acceptable salt of the compound(s) disclosed herein.
  • Other additional ingredients that may be included in the pharmaceutical compositions are known in the art and described, for example, in Remington's Pharmaceutical Sciences (Genaro, Ed., Mack Publishing Co., 1985, Easton, PA), which is incorporated herein by reference.
  • ALK2 refers to activin A receptor, type I (ACVRI), also known as ACVRLK2; SKR1 ; ACVR1A; Activin receptor type I; Activin receptor-like kinase 2; Serine/threonine-protein kinase receptor R1 ; TGF-B superfamily receptor type I; ACTRI; TSRI; activin A receptor, type ll-like kinase 2; activin receptor type-1 ; hydroxyalkyl-protein kinase; ACTR-I; TSR-I. Therefore, an “ALK2 inhibitor,” as used herein, refers to a compound that modulates the activity of ALK2.
  • single formulation refers to a single carrier or vehicle formulated to deliver effective amounts of both therapeutic agents to a patient.
  • the single vehicle is designed to deliver an effective amount of each of the agents, along with any pharmaceutically acceptable carriers or excipients.
  • the vehicle is a tablet, capsule, pill, or a patch. In other embodiments, the vehicle is a solution or a suspension.
  • unit dose is used herein to mean simultaneous administration of both agents together, in one dosage form, to the patient being treated.
  • the unit dose is a single formulation.
  • the unit dose includes one or more vehicles such that each vehicle includes an effective amount of at least one of the agents along with pharmaceutically acceptable carriers and excipients.
  • the unit dose is one or more tablets, capsules, pills, or patches administered to the patient at the same time.
  • oral dosage form includes a unit dosage form prescribed or intended for oral administration.
  • alkyl by itself or as part of another substituent means, unless otherwise stated, a straight or branched chain hydrocarbon having the number of carbon atoms designated (i.e ., Ci-C 6 -alkyl means an alkyl having one to six carbon atoms) and includes straight and branched chains.
  • C1-C3, C1-C4, C1-C6 alkyl groups are provided herein. Examples include methyl, ethyl, propyl, isopropyl, butyl, isobutyl, tert-butyl, pentyl, neopentyl, and hexyl.
  • alkenyl refers to a monovalent group derived from a hydrocarbon moiety containing, in certain embodiments, from two to four, two to six, or two to eight carbon atoms having at least one carbon-carbon double bond.
  • the alkenyl group may or may not be the point of attachment to another group.
  • alkenyl includes, but is not limited to, ethenyl, 1-propenyl, 1-butenyl, heptenyl, octenyl and the like.
  • alkynyl refers to a monovalent group derived from a hydrocarbon moiety containing, in certain embodiments, from two to four, two to six, or two to eight carbon atoms having at least one carbon-carbon triple bond.
  • the alkynyl group may or may not be the point of attachment to another group.
  • alkynyl includes, but is not limited to, ethynyl, 1-propynyl, 1-butynyl, heptynyl, octynyl and the like.
  • alkoxy refers to the group -O-alkyl, wherein alkyl is as defined herein.
  • Alkoxy includes, by way of example, methoxy, ethoxy, n-propoxy, isopropoxy, n-butoxy, sec-butoxy, t-butoxy and the like.
  • C1-C3, C1-C4, Ci- O Q alkoxy groups are provided herein.
  • halo or “halogen” alone or as part of another substituent means, unless otherwise stated, a fluorine, chlorine, bromine, or iodine atom.
  • hydroxyl refers to the group -OH, wherein the oxygen atom is singly bound to a substituent and a hydrogen atom.
  • cyano refers to the group -ON, with a single bond between the carbon atom and a substituent and a triple bond between the carbon atom and the nitrogen atom.
  • cycloalkyl means a non-aromatic carbocyclic system that is partially or fully saturated having 1 , 2 or 3 rings wherein such rings may be fused.
  • fused means that a second ring is present ( i.e ., attached or formed) by having two adjacent atoms in common (i.e., shared) with the first ring.
  • Cycloalkyl also includes bicyclic structures that may be bridged or spirocyclic in nature with each individual ring within the bicycle varying from 3-10, 3-8, 3-7, 3-6, and 5-10 atoms.
  • cycloalkyl includes, but is not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, bicyclo[3.1.0]hexyl, spiro[3.3]heptanyl, bicyclo[2.2.2]octanyl and bicyclo[1.1.1 jpentyl .
  • 3-10 membered cycloalkyl groups are provided herein.
  • Cs cycloalkyl groups are provided herein.
  • bicyclo-Cs cycloalkyl groups are provided herein.
  • bridged-Cs cycloalkyl groups are provided herein.
  • heterocycloalkyl means a non-aromatic carbocyclic system containing 1 , 2, 3 or 4 heteroatoms selected independently from N, O, and S and having 1 , 2 or 3 rings wherein such rings may be fused, wherein fused is defined above.
  • Heterocycloalkyl also includes bicyclic structures that may be bridged or spirocyclic in nature with each individual ring within the bicycle varying from 3-8, 5-10, 4-6, or 3-10 atoms, and containing 0, 1 , or 2 N, O, or S atoms.
  • 3-10 membered heterocycloalkyl groups are provided herein.
  • 5-10 membered heterocycloalkyl groups are provided herein.
  • 4-6 membered heterocycloalkyl groups are provided herein.
  • a cycloalkyl or heterocycloalkyl moiety may be bonded or otherwise attached to a designated moiety through differing ring atoms ( i.e ., shown or described without denotation of a specific point of attachment), then all possible points are intended, whether through a carbon atom or, for example, a trivalent nitrogen atom.
  • pyridinyl means 2-, 3- or 4-pyridinyl
  • thienyl means 2- or 3- thioenyl
  • nitro refers to the group -NO2, wherein the nitrogen atom is singly bound to a substituent, doubly bound to a first oxygen atom, and singly bound to a second oxygen atom. Therefore, the nitrogen atom is positively charged and the second oxygen atom is negatively charged.
  • substituted means that an atom or group of atoms has replaced hydrogen as the substituent attached to another group.
  • a method of treating anemia in a subject in need thereof comprising administering to the subject a compound of Formula I: or a pharmaceutically acceptable salt thereof; wherein
  • Ri is bridged 5-10 membered cycloalkyl optionally substituted one, two, or three times with hydroxyl or C1-C3 alkoxy;
  • R 2 is selected from the group consisting of C1-C3 alkyl, C2-C4 alkenyl, C2-C4 alkynyl, CrC3alkoxy, 3-6 membered cycloalkyl, and 3-6 membered heterocycloalkyl, all of which are optionally substituted with R 3 ; and
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1S,5R)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the myelodysplastic syndrome is selected from the group consisting of MDS with multilineage dysplasia (MDS-MLD), MDS with single lineage dysplasia (MDS-SLD), MDS with excess blasts (MDS-EB), MDS with isolated del(5q), and MDS unclassifiable (MDS-U).
  • the myelodysplastic syndrome (MDS) is MDS with multilineage dysplasia (MDS-MLD).
  • MDS-MLD multilineage dysplasia
  • MDS-SLD single lineage dysplasia
  • MDS-EB MDS with excess blasts
  • MDS-EB MDS with excess blasts
  • MDS-U MDS unclassifiable
  • the subject suffers from multiple myeloma (MM).
  • MM multiple myeloma
  • the subject suffers from a myelodysplastic syndrome and myeloproliferative neoplasms (MDS/MPN) overlap syndrome.
  • MDS/MPN overlap syndrome is chronic myelomonocytic leukemia (CMML) or an unclassifiable MDS/MPN overlap syndrome.
  • CMML chronic myelomonocytic leukemia
  • MF myelofibrosis
  • the anemia is characterized as MF-induced anemia.
  • the subject is transfusion-dependent. In still another embodiment, the subject is not transfusion-dependent.
  • the compound of Formula I is administered orally.
  • the compound of Formula I is administered at a dose of about 5 mg to about 500 mg once daily (QD). In still another embodiment, the compound of Formula I is administered at a dose of about 50 mg once daily (QD).
  • the compound of Formula I is administered at a dose selected from the group consisting of 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 50 mg, 75 mg, 100 mg, 125 mg, 150 mg, 175 mg, 200 mg, 225 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 375 mg, 400 mg, 425 mg, 450 mg, 475 mg, and 500 mg.
  • the compound of Formula I is administered at a dose of 5 mg. In yet another embodiment, the compound of Formula I is administered at a dose of 10 mg. In still another embodiment, the compound of Formula I is administered at a dose of 15 mg. In an embodiment, the compound of Formula I is administered at a dose of 20 mg. In another embodiment, the compound of Formula I is administered at a dose of 25 mg. In yet another embodiment, the compound of Formula I is administered at a dose of 50 mg. In another embodiment, the compound of Formula I is administered at a dose of 75 mg. In still another embodiment, the compound of Formula I is administered at a dose of 100 mg. In another embodiment, the compound of Formula I is administered at a dose of 125 mg.
  • the compound of Formula I is administered at a dose of 375 mg. In another embodiment, the compound of Formula I is administered at a dose of 400 mg. In another embodiment, the compound of Formula I is administered at a dose of 425 mg. In yet another embodiment, the compound of Formula I is administered at a dose of 450 mg. In another embodiment, the compound of Formula I is administered at a dose of 475 mg. In still another embodiment, the compound of Formula I is administered at a dose of 500 mg.
  • the compound of Formula I is orally administered as a tablet. In another embodiment, the compound of Formula I is administered as a 5 mg, 25 mg, or 50 mg tablet, or any combination thereof.
  • a method of treating anemia in a subject in need thereof comprising administering to the subject 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide fumarate dihydrate.
  • a method of reducing hepcidin levels in a subject in need thereof comprising administering to the subject a compound of Formula I: or a pharmaceutically acceptable salt thereof; wherein
  • Ri is bridged 5-10 membered cycloalkyl optionally substituted one, two, or three times with hydroxyl or C1-C3 alkoxy;
  • R 3 is selected from the group consisting of hydroxy, halo, cyano, nitro, SO 2 -C 1 -C 3 alkyl, and SO 3 H.
  • Ri is bridged Cs-cycloalkyl substituted with hydroxy.
  • R2 is tetrahydropyran.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-(3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan- 1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the subject suffers from anemia.
  • the anemia is iron-refractory iron deficiency anemia (IRIDA).
  • the subject is transfusion-dependent. In another embodiment, the subject is not transfusion-dependent.
  • the subject suffers from a myelodysplastic syndrome
  • the myelodysplastic syndrome is selected from the group consisting of MDS with multilineage dysplasia (MDS-MLD), MDS with single lineage dysplasia (MDS-SLD), MDS with excess blasts (MDS-EB), MDS with isolated del(5q), and MDS unclassifiable (MDS-U).
  • the myelodysplastic syndrome (MDS) is MDS with multilineage dysplasia (MDS-MLD).
  • MDS-MLD multilineage dysplasia
  • MDS-SLD single lineage dysplasia
  • MDS-EB MDS with excess blasts
  • MDS-EB MDS with excess blasts
  • MDS-U MDS unclassifiable
  • the subject suffers from multiple myeloma (MM).
  • MM multiple myeloma
  • the subject suffers from a myelodysplastic syndrome and myeloproliferative neoplasms (MDS/MPN) overlap syndrome.
  • MDS/MPN overlap syndrome is chronic myelomonocytic leukemia (CMML) or an unclassifiable MDS/MPN overlap syndrome.
  • CMML chronic myelomonocytic leukemia
  • the subject suffers from myelofibrosis (MF).
  • MF myelofibrosis
  • the anemia is characterized as MF-induced anemia.
  • MF-induced anemia is iron-refractory iron deficiency anemia (IRIDA).
  • the compound of Formula I is administered orally.
  • the compound of Formula I is administered as a monotherapy to reduce hepcidin levels. In another embodiment, a compound of Formula I is administered as a monotherapy not in conjunction with a Janus kinase inhibitor.
  • CDK chronic kidney disease
  • Ri is bridged 5-10 membered cycloalkyl optionally substituted one, two, or three times with hydroxyl or C1-C3 alkoxy;
  • R 2 is selected from the group consisting of C1-C3 alkyl, C2-C4 alkenyl, C2-C4 alkynyl, C1-C3 alkoxy, 3-6 membered cycloalkyl, and 3-6 membered heterocycloalkyl, all of which are optionally substituted with R 3 ;
  • R 3 is selected from the group consisting of hydroxy, halo, cyano, nitro, SO 2 -C 1 -C 3 alkyl, and SO 3 H.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-(3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan- 1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1S,5R)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide fumarate dihydrate.
  • the compound of Formula I is administered as a monotherapy to treat chronic kidney disease (CDK)-induced anemia.
  • CDK chronic kidney disease
  • a method of treating anemia in a subject in need thereof comprising administering to the subject a compound of Formula I:
  • Ri is bridged 5-10 membered cycloalkyl optionally substituted one, two, or three times with hydroxyl or C1-C3 alkoxy;
  • R 2 is selected from the group consisting of C1-C3 alkyl, C2-C4 alkenyl, C2-C4 alkynyl, C1-C3 alkoxy, 3-6 membered cycloalkyl, and 3-6 membered heterocycloalkyl, all of which are optionally substituted with R 3 ;
  • R 3 is selected from the group consisting of hydroxy, halo, cyano, nitro, SO 2 -C 1 -C 3 alkyl, and SO 3 H; wherein the subject suffers from myelofibrosis (MF) and was previously treated with a JAK inhibitor or is not eligible to receive a JAK inhibitor treatment.
  • MF myelofibrosis
  • the subject was previously treated with a JAK inhibitor.
  • the subject is not eligible to receive a JAK inhibitor treatment.
  • the subject is not eligible to receive a JAK inhibitor treatment because the subject is intolerant to the JAK inhibitor treatment.
  • Ri is bridged Cs-cycloalkyl substituted with hydroxy.
  • R2 is tetrahydropyran.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-(3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan- 1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1S,5R)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is administered at a dose of about 5 mg to about 500 mg once daily (QD). In still another embodiment, the compound of Formula I is administered at a dose of about 50 mg once daily (QD).
  • the compound of Formula I is administered at a dose selected from the group consisting of 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 50 mg, 75 mg, 100 mg, 125 mg, 150 mg, 175 mg, 200 mg, 225 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 375 mg, 400 mg, 425 mg, 450 mg, 475 mg, and 500 mg.
  • the compound of Formula I is administered at a dose of 5 mg. In yet another embodiment, the compound of Formula I is administered at a dose of 10 mg. In still another embodiment, the compound of Formula I is administered at a dose of 15 mg. In an embodiment, the compound of Formula I is administered at a dose of 20 mg. In another embodiment, the compound of Formula I is administered at a dose of 25 mg. In yet another embodiment, the compound of Formula I is administered at a dose of 50 mg. In another embodiment, the compound of Formula I is administered at a dose of 75 mg. In still another embodiment, the compound of Formula I is administered at a dose of 100 mg. In another embodiment, the compound of Formula I is administered at a dose of 125 mg.
  • the compound of Formula I is administered at a dose of 375 mg. In another embodiment, the compound of Formula I is administered at a dose of 400 mg. In another embodiment, the compound of Formula I is administered at a dose of 425 mg. In yet another embodiment, the compound of Formula I is administered at a dose of 450 mg. In another embodiment, the compound of Formula I is administered at a dose of 475 mg. In still another embodiment, the compound of Formula I is administered at a dose of 500 mg.
  • the compound of Formula I is orally administered as a tablet. In another embodiment, the compound of Formula I is administered as a 5 mg, 25 mg, or 50 mg tablet, or any combination thereof.
  • Ri is bridged 5-10 membered cycloalkyl optionally substituted one, two, or three times with hydroxyl or C1-C3 alkoxy;
  • R 2 is selected from the group consisting of C1-C3 alkyl, C2-C4 alkenyl, C2-C4 alkynyl, C1-C3 alkoxy, 3-6 membered cycloalkyl, and 3-6 membered heterocycloalkyl, all of which are optionally substituted with R 3 ;
  • R 3 is selected from the group consisting of hydroxy, halo, cyano, nitro, SO 2 -C 1 -C 3 alkyl, and SO 3 H.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-(3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan- 1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1S,5R)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide fumarate dihydrate.
  • MM multiple myeloma
  • Ri is bridged 5-10 membered cycloalkyl optionally substituted one, two, or three times with hydroxyl or C1-C3 alkoxy;
  • R 2 is selected from the group consisting of C1-C3 alkyl, C2-C4 alkenyl, C2-C4 alkynyl, C1-C3 alkoxy, 3-6 membered cycloalkyl, and 3-6 membered heterocycloalkyl, all of which are optionally substituted with R 3 ;
  • R 3 is selected from the group consisting of hydroxy, halo, cyano, nitro, SO 2 -C 1 -C 3 alkyl, and SO 3 H.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-(3-(tetrahydro-2H-pyran-4-yl)-3-azabicyclo[3.1.0]hexan- 1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1S,5R)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide, or a pharmaceutically acceptable salt thereof.
  • the compound of Formula I is 2-amino-N-(4- hydroxybicyclo[2.2.2]octan-1-yl)-5-(4-((1 R,5S)-3-(tetrahydro-2H-pyran-4-yl)-3- azabicyclo[3.1.0]hexan-1-yl)phenyl)nicotinamide fumarate dihydrate.
  • the subject is human.
  • the method or treatment reduces hepcidin serum levels in patients relative to baseline or compared to levels in healthy individuals.
  • the hepcidin serum levels can be reduced by more than about 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%,
  • the hepcidin serum levels are reduced by about 50% or more relative to baseline. In some embodiments, the hepcidin serum levels are reduced to less than about 150 ng/ml_, 140, 130, 120, 110, 100, 90, 80, 70, 60 or about 50 ng/ml_. Hepcidin levels can be tested by standard techniques, including radioimmunoassays, ELISA, ligand binding assay or mass spectrometry.
  • the method or treatment increases serum iron concentration in patients relative to baseline or compared to levels in healthy individuals.
  • the serum iron concentration can be increased by more than about 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or about 100%.
  • Serum iron concentration can be tested by standard techniques.
  • the method or treatment increases hemoglobin serum levels in patients relative to baseline or compared to levels in healthy individuals.
  • the hemoglobin serum levels can be increased by more than about 5%, 10%, 15%, 20%, 25% or about 30%. Hemoglobin levels can be tested by standard techniques.
  • the method or treatment increases transferrin saturation (TSAT) in patients relative to baseline or compared to levels in healthy individuals.
  • TSAT transferrin saturation
  • the TSAT can be increased by more than about 5%, 10%, 15%, 20%, 25% or about 30%.
  • TSAT can be tested by standard techniques.
  • the method or treatment reduces ferritin blood levels in patients relative to baseline or compared to levels in healthy individuals.
  • the ferritin blood levels can be reduced by more than about 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%,
  • Ferritin blood levels can be tested by standard techniques.
  • compositions or pharmaceutical combination comprising the compounds disclosed herein, together with a pharmaceutically acceptable carrier.
  • Administration of the combination includes administration of the combination in a single formulation or unit dosage form, administration of the individual agents of the combination concurrently but separately, or administration of the individual agents of the combination sequentially by any suitable route.
  • the dosage of the individual agents of the combination may require more frequent administration of one of the agent(s) as compared to the other agent(s) in the combination. Therefore, to permit appropriate dosing, packaged pharmaceutical products may contain one or more dosage forms that contain the combination of agents, and one or more dosage forms that contain one of the combination of agents, but not the other agent(s) of the combination.
  • Actual dosage levels of the active ingredients in the pharmaceutical compositions may be varied so as to obtain an amount of the active ingredient that is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient.
  • the selected dosage level will depend upon a variety of factors including the activity of the particular compound employed, the time of administration, the rate of excretion of the compound, the duration of the treatment, other drugs, compounds or materials used in combination with the compound, the age, sex, weight, condition, general health and prior medical history of the patient being treated, and like factors well, known in the medical arts.
  • a medical doctor e.g., physician or veterinarian, having ordinary skill in the art may readily determine and prescribe the effective amount of the pharmaceutical composition required.
  • physician or veterinarian could begin administration of the pharmaceutical composition to dose the disclosed compound at levels lower than that required in order to achieve the desired therapeutic effect and gradually increase the dosage until the desired effect is achieved.
  • the preferred route of administration is oral.
  • compositions and dosage forms include, for example, tablets, capsules, caplets, pills, gel caps, troches, dispersions, suspensions, solutions, syrups, granules, beads, transdermal patches, gels, powders, pellets, magmas, lozenges, creams, pastes, plasters, lotions, discs, suppositories, liquid sprays for nasal or oral administration, dry powder or aerosolized formulations for inhalation, compositions and formulations for intravesical administration and the like. It should be understood that the formulations and compositions are not limited to the particular formulations and compositions that are described herein.
  • compositions intended for oral use may be prepared according to any method known in the art and such compositions may contain one or more agents selected from the group consisting of inert, non-toxic pharmaceutically excipients that are suitable for the manufacture of tablets.
  • excipients include, for example an inert diluent such as lactose; granulating and disintegrating agents such as cornstarch; binding agents such as starch; and lubricating agents such as magnesium stearate.
  • the tablets may be uncoated or they may be coated by known techniques for elegance or to delay the release of the active ingredients.
  • Formulations for oral use may also be presented as hard gelatin capsules wherein the active ingredient is mixed with an inert diluent.
  • the disclosed compounds may be formulated for injection or infusion, for example, intravenous, intramuscular or subcutaneous injection or infusion, or for administration in a bolus dose or continuous infusion.
  • Suspensions, solutions or emulsions in an oily or aqueous vehicle, optionally containing other formulatory agents such as suspending, stabilizing or dispersing agents may be used.
  • kits useful useful, e.g., in the treatment or prevention of diseases or disorders associated with the activity of ALK2, such as anemia, which include one or more containers containing a pharmaceutical composition comprising a therapeutically effective amount of a compound of Formula I, or any of the embodiments thereof.
  • kits can further include one or more of various conventional pharmaceutical kit components, such as, e.g., containers with one or more pharmaceutically acceptable carriers, additional containers, etc., as will be readily apparent to those skilled in the art.
  • Instructions, either as inserts or as labels, indicating quantities of the components to be administered, guidelines for administration, and/or guidelines for mixing the components, can also be included in the kit.
  • reaction conditions including but not limited to reaction times, reaction size/volume, and experimental reagents, such as solvents, catalysts, pressures, atmospheric conditions, e.g., nitrogen atmosphere, and reducing/oxidizing agents, with art-recognized alternatives and using no more than routine experimentation, are within the scope of the present application.
  • the study design will maximize participant safety while important PK information is collected. Dose escalation will proceed with safety information and PK data collected as the study progresses. All AEs (including hematology, blood chemistry, and liver function test abnormalities) will be monitored in all participants to identify occurrences of any safety signal.
  • Additional adverse findings considered to be related to the inhibition of ALK3 at higher doses included mucosal hypertrophy and hyperplasia in the gastrointestinal tract with associated changes in the mesenteric lymph nodes, anagen phase arrest of hair follicles, and further alterations in iron metabolism. Additionally, increased heart rates were observed in dogs at higher doses. Potential increases in heart rate, skin/hair, and the gastrointestinal track will also be monitored clinically.
  • ECG electrocardiogram
  • DLT dose-limiting toxicity
  • MTD maximum tolerated dose
  • RDE recommended dose for expansion
  • Hgb hemoglobin
  • Tl transfusion independent
  • CR complete response
  • PR partial response
  • This Phase 1/2, open-label, multicenter, dose-finding study is intended to evaluate the safety and tolerability, PK, PD, and preliminary efficacy of Compound A administered as monotherapy in participants with MDS or MM who are transfusion-dependent or presenting with symptomatic anemia.
  • the study begins when the first participant signs the informed consent form (ICF). The end of the study will occur when all participants have completed up to 6 months of treatment or have discontinued treatment earlier and completed applicable safety follow-up assessments or when the sponsor terminates the study.
  • the participants who are still receiving Compound A, who are deriving clinical benefit, and who do not have any evidence of progressive disease at time of study closure may have the option to continue receiving treatment with Compound A under this trial or a roll-over protocol.
  • a participant is considered to have completed the study if he/she has completed all stages of the study including the safety follow-up visit.
  • the investigator retains the right to terminate study participation at any time, according to the terms specified in the study contract.
  • the investigator is to notify the institutional review board/independent ethics committee (IRB/IEC) of the study's completion or early termination, send a copy of the notification to the sponsor or sponsor's designee, and retain 1 copy for the site study regulatory file.
  • the sponsor may terminate the study electively, if required by regulatory decision, or upon advice of the data monitoring committee (DMC). If the study is terminated prematurely, the sponsor will notify the investigators, the IRBs/IECs, and regulatory bodies of the decision and reason for termination of the study.
  • the DMC may recommend termination of the study if warranted.
  • Deviations from eligibility criteria are not allowed because they can potentially jeopardize the scientific integrity of the study, regulatory acceptability, and/or participant safety. Therefore, adherence to the criteria as specified in the Protocol is essential. Prospective approval of Protocol deviations to recruitment and enrollment criteria, also known as Protocol waivers or exemptions, are not permitted.
  • ECG Eastern Cooperative Oncology Group
  • Inclusion criteria defining the disease characteristics 6. Participants who are transfusion-dependent or present with symptomatic anemia, defined as follows: a. Anemia: An Hgb value ⁇ 10 g/dL demonstrated during screening recorded on 3 separate occasions with at least 7 days between measurements (Note: RBC transfusion must be at least 2 weeks before the Hgb measurement during screening). b. Transfusion-dependent: Participant has received at least 4 units of RBC transfusions during the 28 days immediately preceding Cycle 1 Day 1 OR has received at least 4 units of RBC transfusions in the 8 weeks immediately preceding Cycle 1 Day 1 , for an Hgb level of ⁇ 8.5 g/dL, in the absence of bleeding or treatment-induced anemia. In addition, the most recent transfusion episode must have occurred in the 28 days before Cycle 1 Day 1.
  • standard treatment options include the following: alkylating agent, glucocorticoids, immunomodulatory drugs IMiD (lenalidomide, pomalidomide or thalidomide), proteasome inhibitors (bortezomib or carfilzomib), and daratumumab.
  • Chronic liver disease e.g., chronic alcoholic liver disease, autoimmune hepatitis, sclerosing cholangitis, primary biliary cirrhosis, hemochromatosis, nonalcoholic steatohepatitis.
  • Gastroesophageal reflux disease not controlled by medication i.e. , currently symptomatic or endoscopic evidence of esophagitis
  • ANC absolute neutrophil count
  • ALP alkaline phosphatase
  • ULN upper limit of normal Primary Analysis and Study Closure
  • the primary analysis will be conducted after all participants have completed at least 6 months of study drug treatment and have completed all safety assessments at Cycle 6 or have discontinued study drug earlier.
  • the participants who are still receiving Compound A, who are deriving clinical benefit, and who do not have any evidence of progressive disease at time of study closure may have the option to continue receiving treatment with Compound A.
  • the end of the study will occur when all participants have discontinued treatment and completed applicable safety follow-up assessments or when the sponsor terminates the study.
  • This study is a phase 1/2, open-label, multicenter, dose-escalation and -expansion study assessing Compound A alone (treatment group A [TGA]) or in combination with ruxolitinib (treatment group B [TGB]), in patients with MF who are transfusion-dependent or present with symptomatic anemia.
  • TGA For TGA, must be either previously treated with JAK inhibitors (for at least 12 weeks and are resistant, refractory, or lost response to a JAK inhibitor), or are intolerant, or are not eligible to receive a JAK inhibitor treatment (e.g., participants who did not receive any JAK inhibitor treatment due to severe anemia and/or without any symptoms except ones due to anemia and without splenomegaly) and have a risk category of intermediate-2 or high according to the Dynamic International Prognostic Scoring System (DIPSS); for TGB, patients must have been on a therapeutic and stable regimen of ruxolitinib for >12 consecutive weeks prior to first dose of study treatment and have a DIPSS risk category of intermediate-1 or -2, or high.
  • DIPSS Dynamic International Prognostic Scoring System
  • ECG Eastern Cooperative Oncology Group
  • Patients are ineligible if they have any other hematologic malignancy; have undergone any prior allogeneic or autologous stem cell transplantation; have undergone major surgery within 28 days of first dose of study drug; or received prior chemotherapy, immunomodulatory drug, immunosuppressive, biological, endocrine, or targeted therapy, or an antibody/hypomethylating agent within 5 half-lives or 28 days before first dose of study drug.
  • Part 1 dose escalation
  • patients will be enrolled into TGA or TGB.
  • Compound A monotherapy will be administered orally at a starting dose of 50 mg/day in TGA (28-day cycles).
  • Dose-escalation stages will use a Bayesian optimal interval design to determine the maximum tolerated dose (MTD), with dose increases not exceeding 100% (2- fold) until a treatment-related toxicity Grade >2 is observed.
  • Dose escalation in TGB will start 2 dose levels below the maximum evaluated dose determined to be safe and tolerable in TGA (recommended dose expansion [RDE]); patients in TGB will receive Compound A in combination with ruxolitinib.
  • RDE recommended dose expansion
  • the primary study objective is to determine the safety and tolerability of Compound A monotherapy or in combination with ruxolitinib (assessed by the frequency and severity of adverse events [AEs], physical examinations, and monitoring vital signs and laboratory values, and identification of dose-limiting toxicities, MTD, and RDE for TGB).
  • AEs adverse events
  • MTD dose-limiting toxicities
  • Secondary objectives are to determine the efficacy of Compound A monotherapy or in combination with ruxolitinib (assessed by anemia response, duration of anemia response, mean change from baseline in hemoglobin, and rate of RBC transfusion through week 24 and 48), evaluate pharmacokinetics of Compound A, and evaluate the effect of Compound A as monotherapy or in combination with ruxolitinib on hepcidin level, iron homeostasis, and erythropoiesis.
  • the anemia associated with chronic kidney disease has been associated with the hepatic hormone hepcidin (Akchurin et al., Am. J. Physiol. Renal Physiol., 2016). Therefore, reduction of hepcidin levels through inhibition of ALK2 would be a useful therapeutic strategy to combat this aspect of the disease.
  • hepatic hormone hepcidin Akchurin et al., Am. J. Physiol. Renal Physiol., 2016. Therefore, reduction of hepcidin levels through inhibition of ALK2 would be a useful therapeutic strategy to combat this aspect of the disease.
  • a murine model of chronic kidney disease that also leads to anemia was used. Orally administered adenine metabolizes to 2,8-dihydroxyadenine, which crystalizes in the tubules of the kidney. Build-up of this metabolite causes kidney injury (nephropathy), inflammation, and subsequently anemia.
  • kidney injury does occur within 10 days of adenine administration, hepcidin levels do increase within 3-4 weeks of adenine administration, and hemoglobin and hematocrit levels do drop after 4 weeks of adenine administration as described elsewhere (Rahman et al., PLoS One, 2018).
  • Compound A dosing began at either 14 or 21 days after adenine administration began and continued for 21 days, followed by one more week until blood analysis.
  • the dosing that began on day 14 was termed “prophylactic” as it began before the increase in hepcidin occurs.
  • Dosing that began on day 21 was termed “concomitant” as the dosing coincided with hepcidin level increase.
  • Figure 2 shows the results of prophylactic dosing in the left panel and concomitant dosing in the right panel.
  • Prophylactic dosing of Compound A led to a dose dependent increase in hemoglobin levels indicating an improvement in anemia in these animals.
  • the 100 mg/kg QD dose of Compound A also returned hemoglobin levels that are within the normal range for C57BL/6 mice.

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